RESUmo
O objeivo deste estudo foi analisar a es -trutura gerencial para o manejo da dor em pacientes com aids em um hospital de re -ferência de Fortaleza, CE, Brasil. Pesquisa descriiva com enfoque qualitaivo, desen -volvida no ano de 2010. Foram realizadas 20 entrevistas com proissionais de saúde (médicos e enfermeiros), analisadas segun -do o referencial da análise de conteú-do. Os dados foram organizados em categorias: condições estruturais favoráveis e desfavo -ráveis. Constatou-se prevalência de condi -ções desfavoráveis no discurso dos entrevis -tados, como ênfase no tratamento farmaco -lógico, inexistência de atendimento especí -ico para dor, insuiciência de proissionais experientes no manejo da dor, demanda elevada e falhas no sistema de referência e contrarreferência. Sugere-se insituir novo modelo gerencial de cuidado aos pacientes com aids, enfaizando atendimento interdis -ciplinar à dor, treinamento de proissionais e aprimoramento de registros em prontuá -rios para uilização de métodos de avaliação e tratamentos mais eicazes.
DEScRItoRES
Síndrome de imunodeiciência adquirida HIV
Dor
Cuidados de enfermagem
Administração dos cuidados ao paciente
Pain management in patients with AIDS:
analysis of the management structure of
a reference hospital
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AbStRAct
The objecive of this study was to analyze the structure for the management of pain in paients with AIDS in a reference hospi -tal in For-taleza, Brazil. This is a descripive study with a qualitaive approach, devel -oped in 2010. Twenty interviews were performed with health care professionals (physicians and nurses), and analyzed ac -cording to the methodology of content analysis. Data were organized into catego -ries: favorable and unfavorable structural condiions. A prevalence of unfavorable condiions was found in the discourse of the interviewees, such as an emphasis on pharmacologic treatment, absence of spe -ciic care strategies for pain, lack of experi -enced professionals in handling pain, and a high demand and failure in the referral and counter-referral system. It is suggested that a new management care model be in -situted for paients with AIDS, emphasiz -ing an interdisciplinary approach to pain, training of health care professionals and improvement of chart records for use in evaluaing pain relief methods and more efecive treatments.
DEScRIPtoRS
Acquired immunodeiciency syndrome HIV
Pain Nursing care
Paient care management
RESUmEn
El estudio objeivó analizar la estructura administraiva para el manejo del dolor en pacientes con SIDA en un hospital de re -ferencia de Fortaleza-CE, Brasil. Invesiga -ción descripiva, con enfoque cualitaivo, desarrollada en 2010. Fueron realizadas 20 entrevistas con profesionales de salud (médicos y enfermeros), analizadas según referencial de análisis de contenido. Los datos se organizaron en las categorías: Condiciones estructurales favorables y des -favorables. Se constató prevalencia de con -diciones desfavorables en el discurso de los entrevistados, con énfasis en el tratamien -to farmacológico, inexistencia de atención especíica del dolor, insuiciencia de pro -fesionales expertos en manejo del dolor, demanda elevada y fallas en el sistema de referencia y contra-referencia. Se sugiere insituir un nuevo modelo administraivo de cuidado al paciente con SIDA, enfai -zando atención interdisciplinaria del dolor, capacitación de profesionales y mejora de historias clínicas para uilizar métodos de evaluación y tratamientos más eicaces.
DEScRIPtoRES
Síndrome de inmunodeiciencia adquirida VIH
Dolor
Atención de enfermería Manejo de atención al paciente
Roberta meneses oliveira1, Lucilane maria Sales da Silva2, maria Lúcia Duarte Pereira3, maria Aparecida Vasconcelos moura4
Manejo da dor de pacientes coM aids: análise da estrutura gerencial eM hospital de referência
Manejo del dolor en pacientes con sida: análisis de la estructura adMinistrativa en hospital de referencia
IntRoDUctIon
In Brazil, pain has become one of the main causes of at
-tendance in emergency situaions and for ambulatories in several medical specialies and other health professions. In paients with acquired immunodeiciency syndrome (AIDS), pain manifests as a common symptom occurring in all stages of the disease with a diferent form for each. The more the disease progresses, higher the incidence and in
-tensity of the pain(1).
Pain is esimated to occur in 90% of people with hu
-man immunodeiciency virus (HIV)(2). Speciically, this pain
occurs for three main reasons: as a symptom or side efect of HIV, another disease or opportunisic infecion, or Ani
-retroviral Therapy (ARVT)(1).
Spreading the main principles of pain management to health professionals who care for people living with HIV/ AIDS involves describing the prevalence and types of pain found in paients with AIDS, analyzing the psychological and funcional impact of this pain, and discussing the bar
-riers to appropriately treaing pain in this group and those with diseases related to AIDS. Moreover, pain control in AIDS paients with a history of substance abuse should be emphasized beyond including oncologists as acive paricipants in the AIDS care(3).
Furthermore, there is a pressing need to analyze the care management systems implemented by insituions because of the importance of the interdisciplinary team tak
-ing increas-ingly individualized acions and paricipaing in the concepion of a mulidi
-mensional model for pain care in paients. When analyzing care management, it is essenial to know the structures the insitu
-ion uses to afect processes related to pa
-ient care, applied resources, the physical
structure, and the availability of treatments among others. For the last 30 years, clinic research has produced therapeuic improvements for paients infected with AIDS; however, problems involving the management and control of pain in these paients have only recently begun being studied(1-4). Therefore, this research aimed to ana
-lyze the structures for managing pain in people with AIDS at a reference hospital for infecious diseases.
Studying the management of pain in hospitalized pa
-ients with AIDS is relevant because it addresses the per
-specive of health professionals on the available tools for efecively managing this symptom at the insituion where they work. It is believed that such an understand
-ing is important for plann-ing soluions in this context.
mEtHoD
This is a descripive study that uses a qualitaive ap
-proach developed in a reference hospital for the treat
ment of infecious diseases in the State of Ceará, Brazil. The physical structure of this hospital includes admission units, intensive care, day hospital care, and specialized ambulatory services for paients with AIDS with daily at
-tendance by professionals who form a mulidisciplinary team.
The studied subjects were health professionals and are listed by convenience. Of the health professionals at the insituion, only doctors and nurses were selected because doctors established the therapeuic regime and nurses managed daily care, assisted paients in their bio
-logical and psycho-logical needs, interacted with the pa
-ients and conducted the exams and procedures required for the paients´ recovery.
The following inclusion criteria were considered: ac
-ive at the insituion for at least one year and assists AIDS paients in the hospital, emergency, day hospital or intensive therapy units. In the end, the study included 20 paricipants, eight doctors and twelve nurses, which was the theoreical saturaion limit for data col
-lected by the survey.
We used a semi-structured interview technique to collect data on the ideniica
-ion, professional background and pain man
-agement pracices of the subjects, which was considered relevant to management and care; the existence of formal or informal pain evaluaion protocols; descripions of the pain management processes performed by the professional; the inpaient care aciviies speciically for controlling pain; and a list of the diiculies with and faciliies for atend
-ing to pain at the hospital. The interviews of the professionals were conducted through
-out the working day and recorded, which al
-lowed for more accurate data collecion. A content analysis of a set of organizaional and infor
-maional techniques was used for the data analysis(5) and
was considered a procedure for analyzing the qualitaive data to ind emergent issues, topics, concepts or knowl
-edge. This analysis was composed of disinct and comple
-mentary phases: previous analysis, material preparaion, material storage, categorizaion, and the explanaion and interpretaion of the obtained results.
The core of this study consisted of 20 interviews de
-ined the phrase as the Record Unit (RU). In turn, the number of RUs was distributed across the themes from the in-depth interviews, which contained common char
-acterisics regarding the service structures considered fa
-vorable (Category 1) or unfa-vorable (Category 2) to efec
-ive pain management.
To ensure the anonymity of the respondents, doctors were codiied with the leter D and nurses with the leter N followed by an Arabic numeral corresponding to the or
-der in which they were interviewed.
for the last 30 years, clinic research has produced therapeutic
improvements for patients infected with aids; however, problems involving the
management and control of pain in
these patients have only recently begun
With regards to ethical issues, this study was approved by the Research Ethics Commitee of the insituion in accordance to protocol nº 063/2009. The professionals signed an informed consent form about the study, which followed Resoluion 196/96 of the Brazilian Health Minis
-try on studies involving humans(6).
RESULtS
Table 1 shows the results of the themaic content anal
-ysis, which used two categories and six subcategories for a total of 51 units.
Table 1 - Distribution of the thematic categories, sub-categories and respective frequencies for the pain management structure for people with AIDS. Fortaleza, CE, Brazil. May/September, 2010
CATEGORIES
(CODIFICATION) f (%) SUBCATEGORIeS (CODIFICATION) f (%) 1. FAVORABLE
STRUCTURAL CONDITIONS (FEC)
13 (25.5) 1.1. Availability of human. material and organizational resources (FECAHMOR) 1.2. Reference hospital (FECRH)
10 (19.6) 3 (5.9)
2. UNFAVORABLE STRUCTURAL CONDITIONS (UFEC)
38 (74.5) 2.1. Lack of speciic attendee for pain (UFECLSAP)
2.2. Shortage of professionals with experience in the pain clinic(UFECSPEPC) 2.3. Elevated demand (UFECED)
2.4. Failure of the references and counter-refers (UFECFRCR)
19 (37.2) 9 (17.7) 7 (13.7) 3 (5.9)
note: n=51
The aspects of pain management discussed by the professionals for paients with AIDS are described by the following categories:
Category 1: Favorable structural condiions
This category included 13 RU and addressed the pro
-fessionals’ percepion on hospital condiions considered favorable to pain management.
Availability of human, material and organizaional resources
When asked about the ease of proper pain manage
-ment at the insituion, the professionals noted the fre
-quent availability of medicines in 10 RU.
the hospital really has all medications! (n8).
We have no lack of medicine; the doctors are considerate and leave everything as prescribed (n9).
the easiest part is that, as soon as the diagnosis is made, the medication is available! (n1).
there is no inter-disciplinary pain treatment; however, we have medicines and professionals for prescription and management (n12).
Other topics, such as convenient organizaional struc
-tures for exams and monitoring paient´s response to their hospitalizaion and treatment, were menioned as rel
-evant to characterizing the service structure as adequate. Such aspects are detailed in the following quotaions:
facilities (we have found) are to conduct an Xr exam,
medicate, and refer a speciic service... (N2).
We have medication on hand, there is the capability with hospitalization where you may pass medication to the in-patient and monitor the response (d4).
The nurses noted their concern and the professionals´ disposiion for assuring the comfort, safety and relief from pain of the paients with the efecive management of this symptom considered favorable.
Whenever he/she mentions pain, we are ready to assist (n7).
When the patient is not feeling very well or feels pain, we put him in an armchair and try to give him some comfort! (n4).
Reference hospital
The surveyed professionals also considered the service structures adequate for pain management considering that the insituion is a reference for the treatment of HIV/ AIDS.
everything is at our disposal, for this is a reference hospital (n9).
as a reference service, we receive many patients and as-sist them! (d1)
there is simplicity because this is a reference hospital… there are medicines, many employees and physiothera-pists, except there is no speech therapy specialist! (d2)
Category 2: Unfavorable structural condiions
This category deserves emphasis based on the quan
-ity of RUs, 38. Half of these address the non-existence of speciic atendees for pain at the insituion and the re
-maining were divided between problems relaing to the shortage of experienced professionals, elevated demand from paients at the insituion and faults in the reference and counter-refers amongst the health units that atend
Lack of speciic atendee for pain
Various protocols and measurements have been devel
-oped and implemented to help professionals beter address pain relief in various health care seings. In this regard, 19 RU detailed concern for professionals in the absence of evaluaion protocols for pain at the insituion despite it be
-ing a reference hospital. The professionals felt the absence of a speciic atendee made promoing directed and indi
-vidualized care more diicult for paients with pain.
Because there is no protocol for dealing with this pain, we do the basics: analgesics and the recommendation of physiotherapy (d3).
Dificulties exist because of the lack of a protocol (N6)
a systematic protocol would be ideal, but we still do not have it (n10).
Shortage of professionals with experience in the pain clinic
The surveyed professionals reported a failure in the processes relaing to the inter-disciplinary management of pain as detailed in nine RU.
sometimes we just medicate patients and do not have a culture of physiotherapy working together (d3).
in some patients (with pain), there is no prescribed pain
medication (N6).
The experience of these professionals was quesioned once the following comment had been analyzed:
For speciic pain management, related to nursing care… there is nothing I consider speciic here! (N4).
One professional conirmed the existence of barriers to atendees of paients in chronic pain.
health professionals do not like attending patients who complain about chronic pain (d7).
Elevated demand
In the professionals´ comments about managing the diiculies found, seven RU emphasized elevated demand from paients at the insituion.
there is a very large demand here at the hospital, and we do not have time enough for the patient (d4).
We have many patients, and there is no means to focus a
speciic treatment in this way, only for pain! (D2)
When he arrives with pain and his doctor is not present,
we must refer him to the doctor’s ofice, and we know he is
going to wait in a queue... (e4)
Failures in the reference and counter-refers
In the interviews, three RU emphasized the failures in the reference and counter-reference system, which were experienced daily.
When it is a headache, you want to refer the patient to a neurologist, and there are none available at the moment! (d7)
references leave much to be desired! (n2)
suspecting pain, i have to send for another service, and i will only know whether the patient has improved after the
appointment, which will be in four months… (D6)
DIScUSSIon
The availability of medicines to invesigaing profes
-sionals represents a favorable condiion for pain manage
-ment. Access to essenial raw materials for controlling pain is discussed as a transversal factor for quality assur
-ance, both from a management-budgeing and technical-scieniic standpoint, which is consistent with several pro
-grams, acions and strategies of the Single Health System (SHS) in Brazil(7).
However, therapeuic intervenion should not neces
-sarily aim at removing causal factors and pain treatments involving pharmacological, physical, anestheic, psychiat
-ric, and funcional neurosurgeries. A guided rehabilitaion to treat disabiliies should be provided by specialized pro
-fessionals who should be capable of clarifying condiions and changing incorrect beliefs(8).
In this context, the ability to manage pain manage
-ment was veriied and indicated that the paricipaion of the professionals and presence of a common work project are essenial condiions to that truly integraing tasks to relieve inpaient sufering. This calls for a uniied mulidis
-ciplinary acivity linked to the composiion, involvement and responsibiliies of each professional on the working staf.
However, we noiced a belief that the insituion, as a reference for the care of HIV/AIDS, had favorable condiions for meeing the various symptoms experienced by these paients including pain. Reference insituions usually con
-tain professionals, materials, equipment and medicaions that overcrowd hospital and decrease its efeciveness. However, the surveyed professionals indicated that the hospital can meet the demand because of the prescripion and availability of medicaions for pain treatments.
These procedures seemed insuicient for meet the user demand in the face of the symptomatology, which required new strategies to improve the quality of care and thus the paient’s life and health condiion.
When discussing unfavorable pain management con
-diions, the lack of a speciic atendee for pain at this insituion was emphasized. This inding corroborates the results of a recent survey conducted at a university hospital in Goiás-Brazil, which revealed the absence of a rouine for the systemaic pain evaluaion of paients by nursing teams and was considered a worrying result(9).
tact paients can more easily analyze the intensity of both their pain and response to pain therapy.
Another study at a private hospital in Fortaleza-Ceará-Brazil demonstrated that nurses had only incipi
-ent knowledge about the systemaizaion of proper pain management despite the constant distribuion of several instruments and procedures for their evaluaion(10).
Mulidimensional tools for pain measurements are ap
-plied in clinics, where a physician has more ime and can beter understand the chronic pain paient. For these pa
-ients, physiological, behaviorist, contextual, and self-re
-corded scales are used to assess the various exising dimen
-sions of pain, which are sensory, afecive, and evaluaive
(11). In a hospital seing, unidimensional scales are used to
measure pain because and only measure the intensity. Despite the large amount of data reported in the lit
-erature, few Brazilians insituions have implemented rou
-ine pain assessments as a ith vital sign, which indicates the need to beter integrate medical and nursing staf to raise awareness on the importance of studying the pathol
-ogy, physiology and treatment of pain and to seek both the paient´s evoluion and the humanizaion of hospital treatments(9).
The respondents had expectaions regarding a speciic protocol to improve pain management despite the imple
-mentaion of this instrument not having been proven. Moreover, the shortage of acive professionals expe
-rienced in pain management at the insituion was em
-phasized. It is known that the inadequate management of pain worsens the health and quality of life of the paient. In addiion, such pain may increase the duraion a paient is admited to the insituion and cause constant hospital
-izaion with repercussions for both the paient and health care service(12).
Adequate pain management begins with a medical evaluaion of the paient, which in turn involves a diag
-nosis that allows therapeuic strategies to be developed. Therefore, it is necessary to insitute an interdisciplinary pain program with competent professionals to work in teams to provide soluions to paients in pain, who are generally searching resources without any saisfactory im
-provement, so that evaluaions and treatments are per
-formed efecively.
The lack of prescribed pain medicaions was empha
-sized and indicates an incipient knowledge and pracice about appropriate management for doctors, which re
-veals neglect seeing as the paients have a right to be evaluated and adequately treated for pain(13).
Another survey discussed problems with the sub-pre
-scripion of analgesics. Nursing professionals menioned the doctor’s dependence on prescripions of this type of medicament, which reinforces the complexity of an inef
-fecive prescripion because the pain was underesimated by the health team(14).
These results also corroborate those from a study de
-tailing the doctors´ percepion about the barriers for the adequate management of pain associated with AIDS. The main diiculies reported were a lack of knowledge on pain management among these professionals, the inac
-cessibility of specialists on the subject and doubts related to the use and potenial addiion of opioid analgesics in these paients(15).
Addiionally, the lack of knowledge of the nursing pro
-fessional (N4) directly responsible for care regarding the ideniicaion of nursing aciviies for pain management is noteworthy. Despite this result, the nurse in the profes
-sional interdisciplinary team currently maintains close contact with the paient and is a pioneer in studying and implemening programs for assessing pain in various sce
-narios(16).
In addiion, when guided by the biological, psychic, and social atendance of human being, nurses can evalu
-ate, examine and implement non-pharmacological strate
-gies for efecive pain relief, which assures the life quality for paients with pain during hospitalizaion.
The unsaisfactory management of chronic pain in pa
-ients with AIDS was the subject of another survey(17). This survey emphasized that, though less frequent than before ani-retroviral therapy implementaion, pain man
-agement remains unsaisfactory and is signiicant problem that should be considered in developed countries where professionals do not always systemaically evaluate the signs and symptoms of paients, and not validated instru
-ments are used for this purpose. This situaion interferes with evaluaing pain and requires more research to ind beter alternaives and instruments.
The data are even more alarming in underdeveloped countries, where professionals ignore their role in ad
-equate pain management and neglect to assist in pain evaluaions, which make the care process fragmented, un
-bound and inhuman.
These issues were exploited by researchers who noted nurses found pain to be underesimated by professionals linked directly to their assistance, which demonstrates that the evaluaion and relief of pain were realized as a secondary factor, while other symptoms were considered a priority to the detriment of pain management(14).
The adequate treatment of pain has relevance to the welfare of human beings; therefore, it is legiimate to recognize and promote the treatment of pain as a fun
-damental human right. Such recogniion will serve as the basis for the legal right to be incorporated into the laws of several countries and will be enforceable through interna
-ional and reg-ional treaies.
Thus, the implementaion of behavioral protocols under scruiny allow for the care, regulaion, evaluaion and control of pain to be improved, while the training and coninued educaion of health staf involves, graduate and technical professionals, is necessary according to the guidelines of the Single Health System in Brazil(10).
Elevated demand was also menioned as one of the primary factors contribuing to the inefecive manage
-ment of pain at this insituion. The emphasis on large numbers of atendee matches the reality of many health insituions where they use a certain way to address work that favors procedures and aciviies over the results and efects for the people under their responsibility. Many hospitals ofer services totally inconsistent with demand and believe that the object of their work is the disease or procedure while devaluing the importance of the com
-plexity and sufering of people(19).
For the Single Health System, some causes may be at
-tributed to the existence of this elevated demand and the challenges accompanying it. One of these causes is the dif
-iculty in planning and discussing the work dynamics for certain services; other reasons would be a compromise between reference and counter-refer for users, informaion on difering health atenion levels, diferent team manage
-ment, the someimes approximate and someimes conlic
-ive representaion of relaionships, contradictory expecta
-ions and conlicts between both health staf and the local powers and the relaionship between health services and the populaion when the team cannot meet demand(20).
It is therefore essenial to evaluate the opening encoun
-ters between health professionals, the user and his social net as a fundamental link in health producion, service re
-organizaion, work process problemaizaion to ensure the intervenion of the muli-professional staf in charge deter
-mining and solving the user´s problem, elaborate on individ
-ual and collecive therapeuic projects, and promote struc
-tural changes through service management, the enlarging of democraic spaces for discussion and decision making, listening, and the exchange of collecive decisions(19).
These acions should be developed by subjects in
-volved in assising the paients, from managers and health professionals to the paients, their family and the commu
-nity. Thus, one can envision individualized care based on the enirety of health care.
Discussions about demand generate other relecions, mainly regarding the completeness of health care, that deepen in the subcategory that talked about reference and counter-refer. These reports point out faults in the references and counter-references amongst the special
-ists and services that care for AIDS paients.
Atenion to health in the SHS is organized in increas
-ing degrees of complexity, with the populaion low-ing in an organized way among primary, secondary and teriary levels through the formal reference and counter-refer mechanisms.
In pracice, this system represents a prescripive pos
-ture atached to formal raionality that does not consider the real needs and lows of those in the health care sys
-tem and therefore ends up for not coming true. Health care operates using very diferent logics that do not aric
-ulate among each other; a soluion to the problem is not assured and the populaion ends up entering the system through all possible doorways(21). It would be ideal for us
-ers to enter through the irst level of care in the health system and be subsequently sent to the other levels ac
-cording to need.
The reality shown by the interviewed professionals in
-volves treaing and monitoring paients with pain and was considerably harmed by the fragility of the reference and counter-refer system with the understanding that these cases are worse due to the urgent need for relieving the paient’s pain as a primary complaint.
Despite advances, mainly relaing to aniretroviral therapy, many challenges sill persist with prevenion and care(22). These people coninue living and facing numerous
consequences of their serum-posiive condiion including sigma and prejudice, which have impact their social, fa
-miliar and sexual relaionships.
Investments in the forming professional processes should be made that improve the client´s health recovery when living under condiions of self-care using simpliied and safe procedures in addiion to the results in hospitals, which are measured using documentaion quality and re
-cords of nursing acions.
Therefore, an important change would be to develop efecive managing pracices and integrate them among those insituions that may treat people with both AIDS and pain. Such pracices make the system of references and counter-references more eicient and ensure that services adequately communicate to coninue providing for this paient at the original insituion.
concLUSIon
The managing structure of a specialized pain man
-agement service for hospitalized paients with AIDS was clearly ideniied. In this context, both the favorable and unfavorable structures in the hospital were analyzed. The availability of material, human resources and orga
-nizaional resources were iniially ideniied as favorable condiions despite the insituion being a reference, which indicates the existence of trained staf to atend to the abundant complains of paients for daily atendance.
The primary factors prevening the adequate manage
-ment of pain at this insituion were ideniied as the large number of paients, absence of speciic atendee or pro
-tocol for managing decisions related to pain and the fre
Despite being considered a reference, this insituion showed a fragile atendee where even the professionals can idenify the advantages and diiculies found in the daily aciviies of treaing pain. Yet, their assistance was informal and based on individual percepions rather than models paterned for treaing pain, such as using scales or instruments to provide a more accurate evaluaion.
The current pain management system in the insituion needs to be reconsidered, which implies a restructuring of the current model for managing inpaient care to improve the material, human and organizaional resources. Work
-ers should be trained to conduct rouine pain evaluaions, and a culture of analysis should be developed for this symptom so that therapeuics are beter implemented to insure the analgesic saisfacion of the paient.
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